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| <div class="noeditbox">Welcome to [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]]. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div> <div class="editorbox">
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| '''Original Editors ''' - [[User:Daan Vandebriel|Daan Vandebriel]], [[User:Glenn Demeyer|Glenn Demeyer]]
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| '''Lead Editors''' - Your name will be added here if you are a lead editor on this page. [[Physiopedia:Editors|Read more.]]
| | • 1 Search Strategy<br>• 2 Definition/Description<br>• 3 Epidemiology/Etiology<br>• 4 Characteristics/Clinical Presentation<br>• 5 Differential Diagnosis<br>• 6 Outcome Measures<br>• 7 Examination<br>• 8 Medical Management<br>• 9 Physical Therapy Management<br>• 10 Key Research<br>• 11 Clinical Bottom Line<br>• 12 References<br><br> |
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| '''Search Strategy <br>'''I first searched the Article Database of the Vrije Universiteit Brussel, further also databases: Web of Knowledge, PubMed, eMedicine, eOrthopod and Science Direct. I used keywords ‘Pes Anserine Bursitis’ or ‘Pes Anserine’ and I started searching for articles who were related to Pes Anserine Bursitis.<br>
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| == Definition/Description ==
| | Check following document<br> |
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| Pes Anserine [http://www.physio-pedia.com/index.php5?title=Bursitis bursitis] as an inflammatory condition of the conjoined insertion of the sartorius, gracilis and semitendinosus. We can locate this at the proximal medial aspect of the knee [15].<br>
| | {{pdf|Pes_anserinus_bursitis.pdf|Pes Anserinus Bursitis}} |
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| == Clinically Relevant Anatomy ==
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| The Pes Anserine bursa is a fluid filled vesicle with the purpose to secrete synovial fluid and hereby reduce friction between two tissues and also works as a cushion for bones, tendons and muscles [16]. The inflammation of the bursa does not appear suddenly but over an amount of time. You can have bursitis in your shoulder, knee, hip, elbow and your big toe. <br>
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| The Pes Anserine, also called the ‘Goose Foot’ is the insertion of the Musculus Sartorius, Musculus Gracilis and Musculus Semitendinosus who are conjoined proximal on the medial side of the tibia. The three tendons who are important to the Pes Anserine are located superficial to the Medial Collateral Ligament of the knee. [1] The Sartorius and Gracilis are adductors of the leg (they pull the leg towards the median axis of the body.) and the Semitendinosus is part of the Hamstrings who are located at the back of your upper leg. These three muscles are primarily flexors of the knee and internal rotators. [2]<br>
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| == Epidemiology /Etiology<br> ==
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| Pes Anserine bursitis often occurs when the related muscles are repeatedly used, by doing movements like flexion and adduction. This causes friction and also increases pressure on the bursa. The bursitis can also be due to a trauma like a direct hit in the Pes Anserine region. Some sports like basketball, dancing and most of all running use movements more often then others and are therefore more likely to cause bursitis then others (These movements are flexion and endorotation because the three muscles who are important to the Pes Anserine are primary flexors but also internal rotators. But also adduction and exorotation.). Other important factors are Pes Planus (flat feet), obesity, age, people with valgus deformities (Because the sartorius, gracilis and semimembranosus protect the knee against valgus stress, so when a person has valgus deformities it means that the 3 muscles are not protecting the knee and that could lead to the Pes Anserine syndrome.), incorrect training techniques (Such as neglecting to stretch, doing excessive hill training and sudden increases of mileage.), diabetes [3] and underlying osteoarthritis of the knee. [4]
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| == Characteristics/Clinical Presentation<br> ==
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| The Pes Anserine Bursitis causes pain on the inside of the knee (mostly during running or taking stairs). Also the region around the bursa will be swollen or tender to touch. [5] It gets most irritated due to activities that require movements like flexion, endorotation but also exorotation and adduction. Pivoting, kicking, squatting or quick movements from side to side. Like in sports mentioned above.
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| == Differential Diagnosis ==
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| Pes Anserine bursitis is often confused with other medial knee pain. To start with a stress-fracture of the shinbone on the proximedial side will cause pain in the area of the Pes Anserine. Another example is the patellofemoral syndrome or arthritis. [6,7,8,9] Panniculitis (http://emedicine.medscape.com/article/308694-diagnosis) is something that happens to people who are obese and will cause just like bursitis more pain at night. Semimembranosus tendinitis will often appear after running of cutting activities just like Pes Anserine bursitis. But also the medial plica syndrome which can cause pain and tenderness on the medial side of the knee are often confused with Pes Anserine bursitis.
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| == Diagnostic Procedures ==
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| Lateral views of the knee of the patient are very useful to say whether or not out patient has to deal with a stressfracture, arthritis or even Osteochondritis Dissecans. But to be sure that we are not dealing with these injuries we have to take an X-ray. To clarify damage caused to other regions of the medial side of the knee, an MRI is needed. This MRI could prevent you from an unnecessary arthroscopy. Of course you have to correlate the MRI with a physical examination. [10,11] Another procedure is a Lidocaine/Corticosteriod injection in the area of the bursa which will help us determine the contribution of this pathology with the pathology of his overall knee.
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| == Outcome Measures ==
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| add links to outcome measures here (also see [[Outcome Measures|Outcome Measures Database]])
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| == Examination ==
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| First of all it’s important to examine the tightness of the hamstring. The patient is in the supine position. Then we bend the hip 90° and the knee is straightened as far as possible. How far the knee can be extended will indicate if the Hamstrings are tight or not and how tight they are (If you can straighten your knee completely than your Hamstrings are not tight.).
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| == Medical Management <br> ==
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| When someone has Pes Anserine bursitis, surgical intervention is something that doesn’t occur. Only when your patient has to deal with a local infection and the standard antibiotic treatment doesn’t work a surgical decompression of the bursa could be a solution.<br>
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| == Physical Therapy Management <br> ==
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| Physiotherapy is the mainstay in the treatment of the Pes Anserine syndrome. To temper the pain that the bursa is causing, the most important thing of all is rest. Take nonsteroidal anti-inflammatory drugs (NSAID) to alleviate the pain, restrict movement, alternate ice (An ice massage of 15 minutes every 4-7 hours will reduce the inflammation.) followed by heat and at last some muscle-conditioning exercises. [12,13,14] <br>
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| Sometimes people get an injection which consists of a solution of anaesthetic and steroid. Afterwards a physiotherapist will give a hamstring stretching program and a concurrent closed-chain quadriceps strengthening program that has to repeated several times a day. This will result in less pain at about 6-8 weeks.<br>
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| == Key Research ==
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| add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>
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| == Resources <br> ==
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| add appropriate resources here <br>
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| == Clinical Bottom Line ==
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| add text here <br>
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| == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) ==
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| see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
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| <div class="researchbox">
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| <rss>Feed goes here!!|charset=UTF-8|short|max=10</rss>
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| </div>
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| == References ==
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| <ref name="[1]">Wood LR, Peat G, Thomas E, et al. The contribution of selected non-articular conditions to knee pain severity and associated disability in older adults. Osteoarthritis Cartilage. Jun 2008;16(6):647-53.</ref> Wood LR, Peat G, Thomas E, et al. The contribution of selected non-articular conditions to knee pain severity and associated disability in older adults. Osteoarthritis Cartilage. Jun 2008;16(6):647-53.
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| <ref name="[2]">Miller RH III. Knee injuries. In: Canale ST, ed. Campbell's operative orthopaedics. St Louis: Mosby; 1998: 1113-1299.</ref> Miller RH III. Knee injuries. In: Canale ST, ed. Campbell's operative orthopaedics. St Louis: Mosby; 1998: 1113-1299.
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| <ref name="[3]">Cohen SE, Mahul O, Meir R, et al. Anserine bursitis and non-insulin dependent diabetes mellitus. J Rheumatol. Nov 1997;24(11):2162-5</ref> Cohen SE, Mahul O, Meir R, et al. Anserine bursitis and non-insulin dependent diabetes mellitus. J Rheumatol. Nov 1997;24(11):2162-5.
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| <ref name="[4]">Stuttle FL. The no-name and no-fame bursa. Clin Orthop 1959; 15:197-199.</ref> Stuttle FL. The no-name and no-fame bursa. Clin Orthop 1959; 15:197-199.<span id="fck_dom_range_temp_1293748535809_633"></span><span id="fck_dom_range_temp_1293748535825_431"></span><span id="fck_dom_range_temp_1293748535825_970"></span><span id="fck_dom_range_temp_1293748535825_595"></span>
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| <ref name="[5]">Forbes JR, Helms CA, Janzen DL. Acute pes anserine bursitis: MR imaging. Radiology 1995; 194:525-527.</ref> Forbes JR, Helms CA, Janzen DL. Acute pes anserine bursitis: MR imaging. Radiology 1995; 194:525-527.<span id="fck_dom_range_temp_1293748538211_380"></span><span id="fck_dom_range_temp_1293748538211_992"></span><span id="fck_dom_range_temp_1293748538211_767"></span><span id="fck_dom_range_temp_1293748538211_704"></span>
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| <ref name="[6]">Safran MR, Fu FH. Uncommon causes of knee pain in the athlete. Orthop Clin North Am 1995; 26:547-549.</ref> Safran MR, Fu FH. Uncommon causes of knee pain in the athlete. Orthop Clin North Am 1995; 26:547-549.
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| <ref name="[7]">Matsumoto K, Sinusuke H, Ogata M. Juxta-articular bone cysts at the insertion of the pes anserinus. J Bone Joint Surg 1990; 72A:286-290.</ref> Matsumoto K, Sinusuke H, Ogata M. Juxta-articular bone cysts at the insertion of the pes anserinus. J Bone Joint Surg 1990; 72A:286-290.
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| <ref name="[8]">Hennigan SP, Schenck CD, Mesgarzadeh M et al. The semimembranosus- tibial collateral ligament bursa. Anatomical study and magnetic resonance imaging. J Bone Joint Surg 1994; 76A:1322-1327.</ref> Hennigan SP, Schenck CD, Mesgarzadeh M et al. The semimembranosus- tibial collateral ligament bursa. Anatomical study and magnetic resonance imaging. J Bone Joint Surg 1994; 76A:1322-1327.
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| <ref name="[9]">Kerlan RK, Glousman RE. Tibial collateral ligament bursitis. Am J Sports Med 1988; 16:344-346.</ref> Kerlan RK, Glousman RE. Tibial collateral ligament bursitis. Am J Sports Med 1988; 16:344-346.
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| <br><ref name="[10]">Zeiss J, Coombs R, Booth R, Saddemi S. Chronic bursitis presenting as a mass in the pes anserine bursa: MR diagnosis. J Comput Assist Tomogr 1993; 17:137-140.</ref> Zeiss J, Coombs R, Booth R, Saddemi S. Chronic bursitis presenting as a mass in the pes anserine bursa: MR diagnosis. J Comput Assist Tomogr 1993; 17:137-140.
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| <ref name="[11]">Hall FM, Joffe N. CT imaging of the anserine bursa. AJR Am J Roentgenol 1988; 150:1107-1108.</ref> Hall FM, Joffe N. CT imaging of the anserine bursa. AJR Am J Roentgenol 1988; 150:1107-1108.
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| <ref name="[12]">O'Donoghue DH. Injuries of the knee. In: O'Donoghue DH, ed. Treatment of injuries to athletes, 4th edn. Philadelphia: Saunders; 1987: 470-471.</ref> O'Donoghue DH. Injuries of the knee. In: O'Donoghue DH, ed. Treatment of injuries to athletes, 4th edn. Philadelphia: Saunders; 1987: 470-471.
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| <ref name="[13]">Larsson LG, Baum J. The syndrome of anserine bursitis: an overlooked diagnosis. Arthritis Rheum 1985; 28:1062-1065.</ref> Larsson LG, Baum J. The syndrome of anserine bursitis: an overlooked diagnosis. Arthritis Rheum 1985; 28:1062-1065.
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| <ref name="[14]">Brookler MI, Morgan EF. Anserina bursitis. A treatable cause of knee pain in patients with degenerative arthritis. Calif Med 1973; 119:8-10.</ref> Brookler MI, Morgan EF. Anserina bursitis. A treatable cause of knee pain in patients with degenerative arthritis. Calif Med 1973; 119:8-10.
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| <ref name="[15]">Moschowitz E. Bursitis of the sartorius bursa: an undescribed malady simulating chronic arthritis. JAMA 1937; 109:1362.</ref> Moschowitz E. Bursitis of the sartorius bursa: an undescribed malady simulating chronic arthritis. JAMA 1937; 109:1362.
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| <ref name="[16]">Tschirch FTC, Schmid MR, Pfirrmann CWA, et al. Prevalence and size of meniscal cysts, ganglionic cysts, synovial cysts of the popliteal space, fluid filled bursae, and other fluid filled collections in asymptomatic knees on MR imaging. AJR Am J Roentgenol 2003; 180:1431–1436.</ref> Tschirch FTC, Schmid MR, Pfirrmann CWA, et al. Prevalence and size of meniscal cysts, ganglionic cysts, synovial cysts of the popliteal space, fluid filled bursae, and other fluid filled collections in asymptomatic knees on MR imaging. AJR Am J Roentgenol 2003; 180:1431–1436.
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